I-131 Therapy Client Information Form

Transcription

1 I-131 Therapy Client Information Form : Owner Name: Spouse/Partner: Address: Home Phone: Work Phone: Cell Phone: Address: Patient Information Pet s Name: Age: Sex: Spayed/Neutered: Yes No Breed: Color: Primary Veterinarian Name: Primary Veterinarian Hospital: Please describe your cat s current appetite: Excellent Good Fair Poor Feeding Instructions: Please write questions or concerns regarding your cat s treatment: Please tell us about your cat (For example, My cat likes his chin scratched. ):

2 Declination of Tapazole Trial I,, understand that it is standard procedure for Veterinary Imaging Center of San Diego (VICSD) to request that my cat,, undergo a Tapazole (Methimazole) trial as part of the screening process for I-131 Therapy. I understand that this trial provides the doctors with vital information that will help them determine if my cat may have a predisposition to kidney problems post I-131 treatment, if my cat is a good candidate for I-131 treatment, and/or if I should pursue other treatment options. My cat either cannot tolerate Tapazole or I have chosen not to follow the above mentioned recommendations and I choose to proceed with I-131 Therapy for my cat. I fully understand and accept any complications that may arise post treatment and do not hold Veterinary Imaging Center of San Diego (VICSD) responsible for these unforeseen problems. Signature of Owner/Agent

3 Consent for I-131 Therapy Owner s Name: Pet s Name: I authorize the Veterinary Imaging Center of San Diego to perform the following procedures on my cat, : ultrasound, thyroid scan, and I-131 radioiodine treatment for feline hyperthyroidism. I understand that, without exception, my cat must be hospitalized for a period of no less than five (5) days. I understand that my cat will be monitored daily and may be released to me only after having reached permissible levels of low-level radioactivity as set by California State Law and Federal Law. I further understand that, in the unlikely event that my cat should pass away during the treatment course, they must remain in the hospital for no less than 90 days before being returned to me or being cremated. I have discussed with the doctor and staff and understand the criteria for admission, treatment, and discharge of my cat from the hospital as well as the safety precautions I must observe following treatment. I understand the risks and benefits of I-131 Therapy and the patient isolation that is necessary, and I consent to the use of this method of treatment for my cat. I understand that a report will be sent to my primary veterinarian and that I will need to arrange an appointment with my primary veterinarian for 1 month, 3 months, and 12 months following discharge for post-treatment blood work. I also understand that I will receive a daily telephone report or from the staff of the Veterinary Imaging Center of San Diego on the condition of my cat. I certify that I understand why this procedure has been recommended, the advantages of any possible complications, as well as any alternative modes of treatment explained to me by the attending veterinarian and/or veterinary assistant. I also certify that no guarantee of assurances have been made as to the results that may be obtained. A deposit of one half of the estimated balance of $1,100 is due upon admission to the hospital. I understand that the remainder of the balance for the I-131 Therapy is due at discharge. I have read, understand, and agree to the above release for I-131 Therapy. Signature Printed Name

4 Today s Schedule The following is a list of all of the procedures that will be performed at our hospital. Health Exam Cardiac Ultrasound: It is important for us to make sure the heart is healthy prior to treatment. Abdominal Ultrasound (Optional): Please let us know if your cat has had any GI upset or weight loss in recent months. Thyroid Scan: We evaluate the thyroid gland function in order to determine our treatment dosage. In fact, this scan is the reason that our treatment success rate is among the best in the country. I-131 Treatment: While we anticipate proceeding with treatment, sometimes issues arise during our pre-treatment assessment. If this is the case, we will contact you, so please make sure you re available at the phone number(s) given to us. Post-Therapy Release Instructions We thank you for entrusting the care of your cat to us for I-131 Therapy. We now must ask for your cooperation and compliance with the laws of the State of California in order to allow continued availability of this type of treatment. Your cat was treated with radioactive iodine on for feline hyperthyroidism, and he or she still possesses a low level of radioactivity. Because some radioactivity will be present for the next two weeks, it is imperative that you agree to and observe the following safety precautions until the date of two weeks post release date. Please keep your cat indoors in order to reduce risk to local wildlife, your neighbors, and your neighbors children and/or pets, as they are unaware of your cat s radioactivity. Anyone under the age of 18 or pregnant women should not change the litter box or come within an 8 foot distance of your cat. For your safety, we recommend that you keep an 8 foot distance from your cat at all times except for 30 minutes a day (30 minutes per person, which can be distributed throughout the day). Please do not allow your cat to sleep with you at night. It is best to keep him or her in an unoccupied room. Avoid face-to-face contact and any contact with your cat s saliva. If you need to give your cat oral medication, please wear the protective gloves we have provided to you. We strongly advise that you wash your hands after any contact with his or her saliva. Cleaning the litter box: Because a small amount of radioactivity is excreted in your cat s urine and feces, please wear protective gloves while cleaning the litter box. (Do not use them for other tasks.) Please clean your cat s litter box

5 daily. We recommend you line the litter box with a plastic liner. If you use flushable litter, flush the toilet twice after depositing the litter into the toilet. If you do not use flushable litter, remove the soiled litter, place it in a plastic bag and then dispose of it in the regular trash outside. If your cat should vomit or soil outside the litter box, perform normal cleaning procedures, wearing your protective gloves. Place all soiled cleaning materials into a plastic bag and then into your regular trash receptacle outside. Wash your hands when you are finished with these tasks. Please keep your cat from walking on kitchen counters. For food preparation, use a cutting board that can be washed and put away when not in use. Should your cat require veterinary care during this two-week period, please provide your veterinarian with a copy of these instructions and notify our doctors as soon as possible. Understand that in the unlikely event that your cat should pass away at home within two weeks following treatment you will need to bring him or her back to our clinic to be held for no less than 90 days before being returned to you or being cremated. Please remember to bring your cat to your regular veterinarian approximately one month following discharge from our hospital to have necessary post-treatment blood work performed. I have read, understand, and agree to comply with the above radiation safety instructions. Signature of Owner/Agent If you have any specific problems or questions regarding these matters, please contact us. (858)

6 CLAIREMONT MESA BLVD. SAN DIEGO, CALIFORNIA P: F: WWW. VICSD. COM Nuclear Medicine Consent Form I have discussed with the doctor and staff the criteria for a nuclear medicine procedure. I understand that although my pet will most likely be released the same day as their procedure, there is a possibility they may require overnight hospitalization. I understand that my pet cannot be released to me immediately after their procedure because of the radioactivity decay guidelines required by the State of California. I understand that veterinary staffing overnight is provided at the discretion of the veterinarian on duty. If I neglect to pick up my pet within fourteen (14) days of written notice that it is ready for release, the animal shall be deemed abandoned. Abandonment, however, does not release me from my obligation for payment of fees. I understand that in the unlikely event that my pet should die at home after their procedure that I am to return them to Veterinary Imaging Center of San Diego to be held until their level of radioactivity is at an appropriate level. A deposit of one-half of the estimated balance of $ is due upon admiscine scan is due at sion into the hospital. I understand that the remainder of the balance for the nuclear medi- discharge. I have read, understand, and agree to the above release for a diagnostic nuclear medicine procedure. I authorize Veterinary Imaging Center of San Diego, to perform a diagnostic nuclear medicine procedure on my pet,. Signature of Owner/Agent

7 I-131 Therapy Reminders Webcams are available online Monday in the late afternoon and Tuesday through Friday from 8:00 a.m. - 5:00 p.m. At cleaning times, the cameras will be turned off temporarily. The webcams will not be turned on during the weekend. During hospitalization, our staff will be in the radioiodine ward twice daily to take care of your pet. Due to restrictions on radiation exposure, our staff is not allowed to enter the radioiodine ward at any other time unless it is an emergency situation. Therefore, if you are online and notice that your cat has spilled their water/food or messed in their litter box, please be patient. We will tend to them as soon as possible. We understand that your cat is a member of your family, and we want them to be as comfortable as possible during their stay with us. We encourage you to bring a small towel or t-shirt and a small toy with you for your cat to lie on. Unfortunately, we are unable to place beds, blankets, or large toys in the cages. Due to state regulations and to ensure the safety of your family, items that are placed in the cage cannot be returned after treatment. Your cat s treatment does not end when they leave our clinic. Follow-up appointments with his or her regular veterinarian at 1, 3, 6 and 12 months post treatment are critical to treatment success. You will receive postcard reminders in the mail from us around each of these time points. At these follow-up visits, your veterinarian will check your cat s thyroid level and kidney function. Your cat s thyroid levels will vary (high, low, or normal) at each visit and it will take some time for the thyroid levels to normalize. Do not be alarmed if the levels are high or low during the initial recheck evaluations. The vast majority of cats do not show any side effects from I-131 therapy. However, difficulty swallowing is the one reported side effect. This may occur in cats with very large thyroid adenomas (benign tumors). Please do not be overly alarmed if your cat has difficulty swallowing after treatment; this is only a transient side effect. You should not see any vomiting, diarrhea, coughing, sneezing, weight loss, hair loss, attitude changes or decreased appetite as side effects of I-131 therapy. If you notice any of these behaviors after your cat returns home, please contact your veterinarian. I-131 therapy has a 98% success rate at our hospital. Therefore, a small percentage of cats may require a second treatment. If this happens with your cat, we will treat him or her again at a reduced rate.